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Borders, Budgets, and the Rising Risk of Disease

Is there a perfect storm brewing along our nation’s southern border? Let’s take a look at the numbers in El Paso, Texas where I recently visited:

There are 27 million crossings per year alone at the El Paso Point of Entry (POE)

Cuts to federal funding including a 50% reduction in the Early Warning Infectious Disease Program as well as 12.5% cuts to critical preparedness and response funding;

Texas is second in the nation for number of tuberculosis cases, the majority of which are found near the border and many of the cases involve tuberculosis strains that are drug resistant

The bordering country, Mexico, was the source of the last global influenza pandemic

So is this a bad situation getting worse or ticking bomb?

An Invisible Public Health Structure

Earlier this month I visited the El Paso POE and came away thoroughly impressed by the professionalism of the Customs and Border Protection. I met many of those “boots on the ground” local public health folks who work on the Texas/Mexico border and who shared with me how the border has been neglected with minimal resources for years. Staff have been forced to live by that old credo “do more with less” to safeguard not only the communities living along the border, but the nation itself.

During my trip I also had the distinct honor to meet and chat with a lawmaker who really understood the importance of border health—U.S. Rep. Silvestre Reyes, D-Texas who notes, “A border crosser with an infectious disease can be anywhere in the United States within 36 hours.” Congressman Reyes knows that the border is a challenging environment with many barriers including different priorities for the two countries who share the border, different public health systems, travel restrictions, language, and politics. Additionally, our public health teams must contend with new and emerging infectious diseases, an economic crisis where budget cuts have decimated public health programs that man the border, and gaps in preparedness.

Disease Threats

While in El Paso, I also met with Dr. David Lakey, Commissioner of Texas Department of State Health Services who discussed his concerns about tuberculosis and other infectious diseases around the border. Lakey pointed out that Texas is second only to California with tuberculosis cases and that these cases are higher near the border than other parts of the state. Lakey said that in the poor communities along the border, people are less likely to get early treatment and often times they travel back and forth across the border and are not able to complete their treatment routine which leads to drug-resistant tuberculosis. Clearly the border is a challenge for those seeking to control infectious diseases.

Valley Fever

In addition to tuberculosis, an emerging disease called coccidiodomycosis or “Valley Fever” seems to be on the rise in this border region. Valley Fever is caused by inhalation of fungal spores that live in the desert soil; the spores can be dispersed by high winds. We see between 10,000 and 15,000 new cases diagnosed in Arizona each year, but very few cases are diagnosed across the Arizona-Mexico border, even though we know that pathogens don’t stop at borders. What is more likely than the pathogen stopping at the border is that health-care providers and laboratories are not trained to recognize and diagnose Valley Fever, allowing it to spread further.

Hard Questions and the Way ahead

How do we conduct surveillance and create sustainable bi-national systems for early warning infectious disease surveillance recognizing that there are 250-400 million northbound legal border crossings a year and that 25% of the US population and 35% of the Mexican population resides in the ten combined Border States? Is doing more with less really the answer? If so, then what can we no longer afford to do? Moving forward we must work to implement guidelines or a process for both countries to coordinate on epidemiological events. We require a bi-national border system for case reporting and communication and outbreak investigations and responses. And finally we must do a better job linking and integrating existing bi-national border efforts.

To learn more about CDC’s Division of Global Migration and Quarantine, which works to prevent the introduction, transmission, and interstate spread of communicable diseases into the United States and its territories, visit: http://www.cdc.gov/ncezid/dgmq/

Tell Us What You Think

Do you live in a border state? Had you ever thought about the importance of public health at our borders? How do you think the nation needs to address the issue of budget cuts and possible disease threats?

28 comments on “Borders, Budgets, and the Rising Risk of Disease”

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I’m glad we are having this discussion.
No, I don’t live in a border state nor do I want to.
Here are some things placed in basic English this country needs.
I feel as a humanitarian that if people outside this county are coming into it, they need to.bring a copy of required immunizations, including comparable immunizations to ours here in the US with matching ssn and given no slack when computers are down per say. I’ve read the latest on the measles & was highly angered that we would be seeing that back here in our states (our pregnant mothers exposed to) or having a possibility in variance in strains.

I live in Tennessee. We have a lot of farms here; they speak no English until their standing in a benefit line at the local health dept. Some do not have proper required green cards to.even be here.

Isn’t it enough of giving ?? That’s the least they could do is get immunizations & wait thru a required waiting period.

Couldnt the US close its borders regardless the cost when these countries have new or old outbreaks of disease ?? We Americans have stepped up to hand hygiene, now why can’t the borders protect us from disease that costs this insurance & nation billions. Is it worth it to risk a loss of a heavy tax payor or someone who has good insurance to an illness brought to this country ?? Has anyone performed statistics to identify the cost?

I see illness when I think about traveling. So I just don’t want to anymore.
I FEEL PRIVILEGED TO LIVE IN A COUNTRY SO HEALTHY COMPARED. I DONT WANT NEW OR OLD DISEASE. I DON’T WANT TO BE EXPOSED TO THEIR DISEASES! SHOULD I BECOME PREGNANT, I DON’T WANT TO BE EXPOSED TO DISEASE.

Use it for a billboard
Thank you CDC for all your work & efforts. How can I help?

Protecting our borders should always be a top priority for so many reasons. The funds must be available and our government officials who are sworn to uphold our laws should be held accountable when they fail to do so. Politicians, officials and other government employees infringe upon the rights of the US citizens when they do not enforce the laws we the people have chosen. Authorities must have the funds, training, manpower and facilities to uphold the law but must also have the support of those above them and any official or unofficial policy to ignore our laws or make them impossible to enforce must be rooted out until such time as those that wish to change the laws get their way through the proper legal process.

This problen is only going to get worses if goverments keep cuttting funding to health programs STOP FUNDING FOR weapons to kill people with.what good idea ?
AND SEND THE MONEY IN THE RIGHT PLACES ,
With air and sea ,train travel its a big problem .we are in changing time let get it right

We do not have to be a border State to be impacted by novel diseases coming into the US. Modern transportation systems can move incubating patients (hosts) from state to state in days or hours. I recall the SARS outbreak and how what read about as a possibility was an issue in northern Michigan within 48 hours. Novel diseases: HIV, West Nile Virus, Monkey Pox, H1N1, all were from foreign origins and mostly from illicit entry in a hosts (exotic animals). We need to be more vigilant of our borders, not less.

I totally agree with this article. I work at a Public Health Laboratory and we see numerous new cases every week. Our numbers are going up and not down as in previous years. Our legislators,Congressmen and Senators should be made more aware of this pending disaster. Talk about “Homeland Security”! We have been occultly invaded by diseases that will be hard to detect and to treat. It is up to us to make them aware.We Public Health Workers should hold themselves up to a higher standard, and participate in our government more so that things like this could not happen.

Opposite to what most of the people wrongly believe: As a fact, Illegals rarely use American public health services.

Illegals hide. They are afraid of jail/deportation. If they get ill, they don’t go to the Dr. until it’s really urgent: In TB this means… MONTHS OF silent SPREADING of the disease. And also, a REAL INCREASE IN PUBLIC RESOURCES SPENDING.

Can you close the border? Can you get ride of illegals? Decades of debate show that you can’t, unless the US Gov. passes an integral-realistic immigration reform.

Do you want to get ride of migration-related diseases?
Smart public health planning should actively engage/target illegals offering full treatment and vaccines for TB infected patients regardless their immigration status.

I agree that the cutbacks in public health funding threaten the systems and structures we have developed to prevent, identify, and respond to health threats, that the experience and relationships that staff have built are lost with the massive lay-offs we have seen in the past three years, and that it will be difficult to recruit new staff to take on what now appears to be an unstable career in public service. However, I question whether enhanced screening at ports of entry would significantly affect the transmission of the diseases you discussed. Coccidiomycosis is not communicable. It is found in the environment, not passed person-to-person. Early detection of TB by clinicians, proper treatment, and effective contact identification, testing, and treatment are the key to controling the spread of tuberculosis. The US-Mexico Binational Tuberculosis Referral and Case Management Project is more likely to reduce drug-resistant tuberculosis than screening at border crossings. CPB officers are the eyes and ears of the CDC Division of Global Quarantine, and improved ability to recognize and respond appropriately to ill travellers is important. So is the coordination between local, state, and federal public health agencies, and between public health agencies, medical organizations, and other social service and public safety agencies. I work in public health at a county with a busy border crossing with Canada and we have been involved with our state, federal and Canadian partners in the Pacific Northwest Border Health Alliance. All of these organizations have to be sustained, and the network strengthened, to be able to effectively identify and respond to high-risk cases, outbreaks, epidemics, and pandemics.

The comment regarding Valley Fever is incorrect. The incidence in humans, dogs and cattle in Southern Arizona is increasing. Often the dermal test for TB in humans and cattle provides a false positive as a result of VF. Very few dogs in the Tucson area are not sero +

Im a Family Physician in Anthony NM, right at the state line of Texas and New Mexico, 18 minutes away from the border city of Juarez. I think I have more experience in both sides of the border, I worked as a Physician in Ciudad Juarez before coming to the US. The budget cuts are not a good thing anywhere. The great movement of people across the country lines has continued to grow because for the people in Mexico the border continues to be the most productive area. The violence started almost 4 years ago, (I remember I was still a resident and used to commute every single day to Las Cruces from Ciudad Juarez) made this population movement to the US even bigger. I even ended up moving here for the same reason. And not necessarily every person that moved is illegal. Many of the people that moved were US citizens or US residents, wealthy families, medium income families, all those people lived in Mexico. That increased the population in the southwest region. I agree to some extent that there are some illegals but I dont think you are seeing a great percentage increase. But let’s not forget all the population movement from Arizona after they were hunting down people for “driving while brown”, many of these people also contributed to the growth of the region, people that paid their taxes, were legal residents and workers but the fear caused them to move away. I think budget cuts are important to the region since these situations have not been considered. El Paso was one of the fastest growing small economies in the country. New Mexico has underserved areas closed to the border where health services are barely available. I think that budget decisions are not necessarily made by people who take care of people. Until the problem is addressed deeply working alongside with the providers that serve not the population of the border per se but the underserved population that live here, probably all these cuts could be avoided. I believe is just a matter of understanding that the border is a place slightly different than the rest of the nation.

Is not a matter of speaking English or Spanish, being Illegal or not, is a matter of the huge event called population mobility that exists in the area. Either if is casual or not, or population displacement by the violence.

I live in Alabama which is not a “border state” but we do have a port city. Consequently, we have high numbers in diseases such as tuberculosis, HIV, etc. I have recently discovered that due to budget shortfalls our state’s public health departments have cut funding for tuberculosis control. This forces patients to seek diagnosis and treatment from the private healthcare setting. While this setting is capable of treating those who seek care from it, typically those who contract tuberculosis are in the lower economic category. They will probably not seek treatment, or if they do , may not complete treatment due to the cost of the drugs. I am generally not in favor of increasing “free healthcare”, but when restricting or eliminating the programs that reduce EVERYONE”S risk are involved I do feel that government has its place. I am not aware of other cuts that may have been made in the budget, but this particular one does not seem to have been a wise choice.

I have emailed the state’s health department to varifiy this information. I am hoping that the individual I spoke with at our county’s board of health is incorrect or just misunderstood the new regulations regarding tuberculosis control in our area.

I very much appreciate that you are paying attention to this serious problem with the border and public health. In addition to tuberculosis, there is also an emerging threat with Chagas disease connected with continued illegal migration of people from South and Central American into North America. People are not being screened for diseases. There is also a public health threat with lax border security and our on-going wars in Middle Eastern countries. Legal immigrants are screened at controlled borders, which helps to limit our exposure to many threats, pandemics, terrorism, etc. Thank you.

I worked as a physician south the border and I have experienced the effects of the lack of interest from both governments for developing comprehensive binational health policies that benefit the constant flux population between Mexico and the US. There is a common misperception that immigrants are a free-load to the system, all of them contribute to the economy, and most of them regardless of their status are subject to pay roll taxes. Preventive health policies that include universal immunization coverage and the implementation of a binational epidemiologic surveillance system are some of the measures that will surpass the economic expenses by bringing more benefits in the long term.

In support of the need for open and timely cross border collaboratiion the Pacific NorthWest Border Health Alliance (PNWBHA) provides seamless cross jurisdictional public health surveillance and emergency response network in the Pacific Northwest. The PNWBHA goal is to provide leadership in the integration of health sector preparedness and response initiatives at all levels of government, including Tribal and First Nations, throughout the Pacific Northwest. While significant progress has and continues to be made in expanding the collaborative web we remain resource, particularly financial, challenged. If we are to move forward in addressing pan border public health preparedness all levels of government must be prepared to actively participate in (and contribute to) the process.

The spread of Valley Fever will not be stopped by a lack of health documentation. With regard to Chagas disease i have read that it is on the increase due to the fact that there is only one factory producing pills and it is in Brazil. They are not producing enough of the medication, possibly because there is not enough money to be made.

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